'-COMPARATIVE ASSESSMENT OF THE … Attributes of ... ature concerned with maternal diet in puerperium, ... found no change in the meal pattern of the mothers during ...

'-COMPARATIVE ASSESSMENT OF THE NUTRITIONAL STATUS

OF HAITIAN CHILDREN; DURING THE TRANSITIONAL PERIOD

IN TWO HAITIAN COMMUNITIES

by

Ma. Stella.Gonzales

Thesis submitted to the Graduate Faculty of the

Virginia Polytechnic Institute and State University

in partial fulfillment of the requirements for the degree of

APPROVED:

R. W. Engel

C. L. Miranda

MASTER OF SCIENCE

in

Human Nutrition and Foods

R. E. Webb, Chairman

February, 1975 Blacksburg, Virginia

J. A. Ballweg

S. S. Ward

ACKNOWLEDGEMENTS

The author wishes to express her deep appreciation to

for their guidance, encouragement and tech-

nical assistance. Special thanks are given to

Director of Haitian Bureau

of Nutrition. The help and encouragement of numerous friends are sin-

cerely appreciated.

ii

TABLE OF CONTENTS

Acknowledgments

List of Tables

List of Figures

Introduction

Theoretical Framework and Review of the Literature

The Ecosystem Approach Maternal Diet in Puerperium Breastfeeding and Weaning Habits Transition Period Diet

Methodology

Sampling Procedure Village Selection Village Description Respondents

The Instrument Anthropometry Weight Height

The Survey Team Sight of Field Examination and Line of Flow

Definition of Major Terms

Scope and Limitations of the Study

Results and Discussion

Maternal and Family Characteristics Characteristics of the Child Additional Observations

Summary and Conclusions

Literature Cited

Appendix 1

iii

ii

v

vi

1

4

4 9

11 14

19

19 19 19 23

23 24 24 24

25 25

26

27

28

28 33 38

42

44

48

Appendix II

Appendix III

Appendix IV

Appendix V

Vita

iv

59

60

61

62

63

Table

1.

2.

3.

4.

5.

6.

7.

8.

LIST OF TABLES

Age of Mother in Relation to the Nutritional Status of the Child.

Literacy Level of Mother in Relation to the Nutritional Status of the Child.

Distribution of Children According to Number of Siblings and Nutritional Status.

Distribution of Children According to Age in Months and Nutritional Status.

Distribution of Children According to Sex and Nutritional Status.

Distribution of Children According to Type of Infant Feeding (Milk) and Nutritional Status.

Distribution of Children According to Age at First Introduction of Semi-solid Food and Nutritional Status.

Distribution of Children According to Weaning Practice and Nutritional Status.

v

Page

29

30

32

34

35

36

37

39

Figure

I.

II.

III.

LIST OF FIGURES

A Conceptual Model for the Study of Nutritional Status of Children.

The Family as Environment

Nutrient Intake of the Child

vi

Page

5

7

8

INTRODUCTION

Nutrition is an emerging dynamic science concerned with man in

health and disease, multidisciplinary in scope and holistic in approach.

The important link between diet, skilled manpower and productivity

potential has led to an increasing awareness of nutritional adequacy

as important to both the health of the people and a requirement for

development and public policy. In essence, the problem of malnutrition

challenges the economic growth of developing nations.

It has been documented that the pre-school child is at the vulner-

able age in human development (Gyorgy, 1970). By necessity young

children are dependent on others, primarily members of the family. Pro-

vision for nutrient supply, emotional support and intellectual stimula-

tion is essentially a family affair. Cultural practices and values

transmitted through close association with the family largely influence

the pattern of growth and development of the child.

According to Jelliffe (1966):

The situational background of poor economic condition, high illiteracy level and minimal socio-medical facilities provide fertile ground for attitudes, customs and predjudices to exert great significance.

It is therefore, evident that new nutritional knowledge pertinent to

peasant economics is needed.

Confronted with a comparable situation and cognizant of its limited

resources, the Haitian government, like other developing countries, has

instituted several measures to combat its nutritional problems.

Several studies have noted the deficiencies in the Haitian diet

1

2

(see King et al (1968), Jelliffe and Jelliffe (1961), Sebrell et al,

(1959) and Grant and Groom (1952). Fougere (1968) reported that 68%

of Haitian pre-school children were suffering from malnutrition of one

degree or another and approximately 7% suffered from kwashiorkor. Ex-

tending Jelliffe's findings on 1,322 pre-school children to the entire

Haitian pre-school population, Fougere estimated that 255,830 individuals

were undernourished and 26,336 suffered from kwashiorkor.

The 1972 census figure for Haiti (Population Progress Assistance,

1972) included an estimated population of 5,021,000 (Jan. 1, 1972); a

birth rate per 1,000 and death rate per 1,000 of 44 and 18 respectively.

The infant death rate in 1970 was reported to be 130 per 1,000. Per-

centage literacy was 10, while there was a 2.6% rate of natural increase.

The poor agricultural economy, seasonal variations and the old

traditional beliefs in child feeding practices have been considered

major factors contributing to the prevalence of malnutrition (Jelliffe

and Jelliffe, 1961).

The study reported here encompasses the following objectives:

1. To ascertain the prevailing child feeding patterns, weaning

habits, beliefs and practices during pregnancy and lactation of mothers

in the Haitian villages of St. Michael and Lalomas. Efforts were

directed specifically toward determining:

(a.) the type of infant feeding (milk) in each community

(b.) the duration of lactation (breastfeeding) and other forms

of milk feeding (bottle and mixed).

(c.) age at introduction of first semi-solid.

3

(d.) qualitative characteristics of the transitional diet.

(e.) food beliefs and practices during pregnancy and lactation.

(f,) attitudes of mothers regarding scientific prenatal care.

(g.) mother's concept of illness in relation to weaning.

2. To explore the relevant associations between demographic

variables such as family composition (number of siblings) and maternal

characteristics (age, literacy level, occupation), and the nutritional

status of the sample population.

3. To determine the impact on the conununity of the mothercraft

center (nutrition education program) measured in terms of the nutrition-

al health of the sample children. This impact will be approximated via

a comparative analysis of the nutritional status of the participant

(sample) children in each conununity based on anthropometric measurements

such as weight, height, head and chest circumference, mid-arm circum-

ference, and skinfold thickness.

From the above it can be seen that this study attempts to explore

the association between feeding pattern and nutritional status of the

participant children.

THEORETICAL FRAMEWORK AND REVIEW OF THE LITERATURE

Sims (1970) contends that:

The syndrome of malnutrition occurs not in isolation but consists of an entire constellation of environmental factors which together contribute to final manifestation of the problem. Nutrient intake has been recognized as an important environmental factor which acts upon the genetic potential of the child to influence his growth and development.

Additionally, Sims et al (1972) acknowledge Johnson's statement that:

"the study of nutrition is a study of ecology and for valid assessment

the whole of the environment must be examined." Within this context,

the present research focuses on the Ecosystem Approach as the ecologi-

cal model most appropriate for the study of the nutritional status

of the pre-school child in relation to the home and family environment.

(Figure 1)

In classical terms, ecology is the science of the relationship

between an organism and its environment. A system is a set of compo-

nents which act with one another to bring about a balance, interde-

pendence or wholeness. (Havelock, 1971).

The Ecosystem Approach - The salient characteristic of the eco-

system framework considers the living system as composed of matter and

energy organized by informations (Miller, 1971). Hanlon (1969) suggested

that:

Man is an open system through which the energy, resources, and influences of the environment are transformed for good or ill, and which transforms man in the process.

The matter-energy flow related to the provision of food from

the environment, is utilized by the organism and manifested in an

4

5

A CONCEPTUAL MODEL FOR THE STUDY OF NUTRITIONAL STATUS OF CHILDREN

INPUT

OUTPUT

T H E E N V I R 0 N M E N T

v THE FAMILY

MATTER-ENERGY

Nutrient Intake of Child

v

(THE CHILD AS ECOSYSTEM)

-Or

~hysical Growth; Nutritional Status

Figure I.

6

output of energy needed to carry out growth and maintain life. The

information flow within the system is appropriately illustrated by

the "wheel communication network." In this model, the mother in a

nuclear family represents the major link between the outside environ-

ment and other members of the family, being responsible for the prep-

aration and distribution of nutritional energy (food) within the house-

hold (Katz and Kahn, 1966). (see Figure II.)

For the effective utilization of the systems approach, it is

necessary that the environmental factors impinging upon the system

be identified. According to Rafalski and Mackiewicz (1968) man dis-

tinguishes two types of environment: the physical and biological,

which are independent of man, and the social, cultural and economic

features of the environment which are closely associated with human

existence.

Two system definitions are considered in this conceptual frame-

work, the family as an ecosystem and the child as an independent eco-

system. The first system is based on the premise that the family

plays the key role in providing the child with the environment through

which matter-energy and information are transmitted and resources are

utilized to enable him to meet his growth potential.

The second system (the child as an independent ecosystem) was

developed as an extension of the general ecosystem approach to

studying the nutritional status of the pre-school child. Sims (1970)

postulated that the nutrient intake of the child represented the most

significant linkage between the family system output and the child's

nutritional status. (see Figure III.) Jessor and Richardson (1968)

I.

II.

III.

7

THE FAMILY AS ENVIRONMENT

Variables

Current Family Setting (Demographic Data)- - -+

Resource Availability and Use--------+

Social-psychological Attributes of Mother--+

A.

B. c. D. E.

Measures

Socioeconomic Status 1. Income 2. Education 3. Occupation Ethnicity (Race) Family Composition Family Stability Mobility

Physical description of the "near" environment, including: nutrition knowledge, attitudes refeeding children, food buying practices, use of space, housing conditions

A. Semantic differential: "How I See Myself As Mother" instrument.

B. Anemic C. Powerlessness D. Parental Attitudes on

Child-rearing (PARI Instrument)

E. Homemaker Values Scale

Figure II.

8

NUTRIENT INTAKE OF THE CHILD

Variables Measures

Dietary - - - - - - - - - - + jA. 3, 24-hour Feed Records Evaluation ~· Dietary History of Child

v (THE CHILD AS ECOSYSTEM)

v Physical Development; Nutritional Status

I. Biochemical Indices---- - ----+

II. Anthrope-metric Measures--------+

A. Blood: 1. Hemoglobin 2. Hemotocrit 3. Total serum proteins 4. Serum albumin

B. Urine: hydroxpreline creatinine ratio.

A. Height; standing sitting

B. Weight C. Skinfold thickness:

triceps, subscapular D. Circumferences:

head, upper arm, chest E. Diameters: biacromial,

bicristal.

Figure III.

9

indicate that demographic variables (including race, economic status,

family composition, maternal characteristics, age, education, occupa-

tion) have been included, since these factors influence food habits

and consequent food intake of the pre-school child.

Nutritional anthropometry has been utilized in the present study

to measure physical variation and different levels of nutrition rele-

vant to the variables under consideration. The growth rate of children

has been cited as one of the most simple, inexpensive, reliable and

important tools by which to assess nutritional status (Food and Nutri-

tion Board, 1956).

Prior to an in-depth examination of the procedures adopted in

carrying out this study it is first necessary to review the research

which has been conducted in related areas. Specifically, the liter-

ature concerned with maternal diet in puerperium, and other related

topics will be examined.

Maternal Diet in Puerperium.

In a report by Jelliffe (1962), mothers in Guatemala were given

broth from chicken or beef after delivery or during lactation to pro-

vide strength and promote milk secretion. Among the Bagandas in Africa,

good protein foods (meat and eggs) were tabooed from the mother's diet.

Food was restricted for forty days following delivery among Chinese

mothers in Singapore as well. These special dietary practices during

puerperium were classified by Jelliffee as either nutritionally bene-

ficial or harmful.

In a study of infant feeding in a small Filipino village, Nurge

10

(1957) found no change in the meal pattern of the mothers during

pregnancy. However, during lactation practices to enhance abundant

milk flow were encouraged. Broth from clams, fish, vegetables, chicken

and beef were considered good galactagogues.

As practicing physician in Mandala, Burma, Sharma (1955) observed

that the major cause of high infant mortality was beri-beri, due to a

diet consisting mainly of large quantities of polished rice with small

amounts of dried fish, pulses, oil and salt. The excessive intake of

rice was to replace nutritious foods which were believed to result in

large babies.

In Haiti, Jelliffe and Jelliffe (1961) pointed out that dietary

restriction was not common during pregnancy. In addition, some village

women did not eat fresh fruits, fish, eggplant, white beans or pork

two to three months after delivery.

Kelly (1956) found identical ante-partum food habits among Mexican

women. The mothers generally excluded all cold foods such as fruits

and vegetables for one month after delivery and subsisted mainly on

hot foods such as chocolate, coffee, tea, cinnamon and meat of a laying

hen. Cold foods were believed to cause diarrhea.

Two study cases illustrate the impact of social mobility on

dietary pattern. Hussain and Wadsworth (1967) reported a decline in

the avoidance of certain foods by a group of Pakistani mothers who

moved to Bradford, England. They surmized that the benefits of obstet-

rical service, the exposure to modern food patterns, the desire to belong

to a new cultural group and adopt its food practices were reasonable

11

bases for the change in feeding habits. Gan (1967) drew attention to

the breastfeeding performance of a group of West Indian mothers in a

number of out-patient clinics in London, England. He stated that it

was common practice to terminate breastfeeding once maternity benefits

ceased, in spite of excellent lactation potential. Whereas economics

was the criteria for the altered pattern among the West Indian mothers,

status was the more significant factor among the Pakistani mothers.

Gopalan (1958), in a study of fourteen malnourished lactating

Indian mothers, stated that for those subsisting on 60 gram protein

with an output of 50 to 60 grams of protein from breastmilk daily,

protein supplementation was without any beneficial effect in enhancing

milk secretion. He contended that the demands of lactation were so

great that when dietary protein was not available maternal tissue was

sacrificed to meet the protein requirement. Therefore, protein supple-

mentation was not manifested in increased milk flow but rather in a

correction or replacement of tissue protein deficit. Thus, adequate

improvement of the diet during pregnancy was essential to avoid maternal

protein depletion and thereby ensure successful lactation.

Breastfeeding and Weaning Habits - Several studies confirm

breastfeeding as the mainstay in infant diet for most rural mothers

in developing countries. From interviews of 707.Haitian mothers with

0-4 year old children, Jelliffe and Jelliffe (1961) found successful

lactation (99%) during the first six months of life, with a gradual

decline to 81% in the second six months. Over 50% were still breast-

feeding at 12-18 months while 9% continued to do so from 18-24 months.

No subject was breastfed after two years.

12

Rao et al (1959) reported a similar trend among poor connnunities

in Southern India, where 92% of the infants were breastfed for six

months and over 50% up to 18 months. One child out of 5 still received

mother's milk beyond two years; only two percent were not completely

weaned at three years. According to Guthrie (1964) rural-urban figures

for breastfeeding among 245 Filipino mothers were 86% and 41% respective-

ly, with an average duration of 13-18 months.

Gyorgy (1970) reported that recent trends in infant feeding indicate

a rapid decline in breastfeeding practice, this pattern being consistent

in the rural-urban populace throughout the world. In Guatemala, 98% of

rural Indian children continue to nurse after their first burthday. In

Indonesia the comparable figures are 90% and 70%. In Taiwan 97% of the

rural mothers were found to breastfeed for 6 months as compared with 61%

of their urban counterparts. In Gambian cities lactation ends between

6 and 9 months after delivery, while in rural areas weaning occurs be-

tween 12 and 24 months. In one rural Mexican village in the years 1960-

1966 the percentage of infants under six months of age who were solely

breastfed declined from 95 to 73. For the state of Arkansas, U.S.A., in

the year 1946, 84% of the infants were breastfed (totally or partially)

compared with 22% in 1966. Analogous figures for California were 60%

and 38% respectively.

Data from a Brazilian study (Gyorgy, 1970) on 879 public maternity

centers show that 44% of infants were fully breastfed for one day post-

partum. In 1949 95% of Chilean mothers breastfed up to 12 months while

only 6% did so in 1969. Similar declining trends in breastfeeding among

13

urban elite were observed in the West Indies, Trinidad, and Jamaica.

The shift from the use of mother's milk to artificial formula

together with progressively shorter periods of nursing, coupled with

urbanization and social mobility have strong implications for the inci-

dence of malnutrition among increasingly younger children.

Jelliffe (1966) contends that for most tropical and subtropical

countries, prolonged breastfeeding is the prevailing practice. The

average age at weaning varied from 13 months to 3 years. The majority

of the mothers claimed preference for mother's milk because it was

inexpensive and breastfed children were healthier than their arti-

ficially fed counterparts. Jelliffe further pointed to the contracep-

tive function of prolonged lactation as a strong cultural belief held

among rural mothers in many parts of the world.

In an investigation undertaken in the rural parish of Crulai,

Normandy in 1674-1742, Tietze (1961), showed that the mean interval be-

tween two successive live births was 30.5 months if the older child

lived to one year compared to 20.5 months if the child died in infancy.

Post-partum infertility was 4 months for non-lactating women, but varied

among lactating mothers. Prolonged amenorrhea tended to be associated

with lactation.

It has been reported that a prolactin inhibiting factor present

in the hypothalamus is greatly depressed by sucking stimulus, with

release of milk secretion (WHO, 1965). The concept still stands that

in the absence of ovulation during amenorrhea or lactation, conception

is rare.

14

Welbourn (1966) mentioned that in Baganda, Africa, it was the

belief that milk of a pregnant mother was poisonous to the suckling

child. It was on this premise that the most common reason for weaning

among village mothers was the onset of another pregnancy.

Herskovits (1937) stated that complete weaning from the breast

can be accomplished either gradually or abruptly. Connnon village

methods included painting of the breast with bitter substances (pepper,

lalua, garlic), sleeping apart from the child, giving herbal infusion

or offering the child his favorite food. The abrupt weaning by

physical separation has been considered by many workers as the most

traumatic process precipitating kwashiokor in borderline cases of mal-

nourished children. The anorxia frequently observed after weaning

aggravates the already precarious nutritional state of the young

toddler. The cumulative effect of emotional deprivation, inadequate

mother's milk, and a highly contaminated nutritionally deficient trans-

itional diet mark the weaning period as a crucial phase in child's

growth and development.

Transition Period Diet - In recent years the term transition

period has come to be associated with weaning time (Cameron and

Hofvander, 1971). Jelliffe and Jelliffe (1961) reported the trans-

itional diet of 129 infants and 377 1-4 year old San Blas Indian

children of Panama. Food was introduced in the second half of the

first year of life to two-thirds of the children. It consisted mainly

of ripe mashed banana and yam cassava boiled into a puree. Fish,

although in abundance, was not given because the bones were considered

dangerous to the child. Modified adult diet was introduced in increas-

15

ing amounts during the second year.

Cross cultural reports note common transitional foods such as

mashed steamed plantain and sweet potato from Baganda, maize and

mashed banana in Haiti, cereal products such as strained rice in Burma

and Southern India, mashed banana and rice gruel in the Philippines,

and maise gruel in Latin America. It was evident from the above that

the semi-solids introduced lacked protective foods (Welbourn, 1966;

Jelliffe and Jelliffe, 1961; Sharma, 1955; Jelliffe, 1966; Guthrie,

1964; Nurge, 1957; Sanjur et al, 1970).

Sanjur et al (1970) cited studies of feeding attitudes in rural

areas where the families, through empirical reasoning, have established

their own concept of causal relationship between food and disease, with

the result that foods of high protein value were considered harmful to

the child. Meat was considered indigestible for the young child's

stomach. Colostrum was also discarded as a waste product. It is a

traditional African practice that meat and the best portion of the

family meal be reserved for the male member of the household (Welbourn,

1966).

Wellin (1958) mentioned the belief in the inter-relatedness of

child feeding practices to defined body image as the dirty stomach

concept. It was a common practice to institute therapeutic starvation

and purgatives in cases of diarrhea to clean the stomach and rest the

intestine.

It has been well recognized that improved availability of food

becomes significant only to the extent that it leads to proper utili-

zation in the child's dietary pattern. Unfortunately, cultural blocks

16

which influence food consumption are often the decisive ones. Nutrition

education in the more traditional connnunities is so difficult because

one has to displace deep seated beliefs and supply knowledge where there

is none.

Malnutrition and Infection - Infant and toddler mortality are

important indices of the stresses that disease and malnutrition play

in the distortion of normal growth and development of a child in the

crucial formative years (Gordon and Scrimshaw, 1970). The synergistic

action of infection and malnutrition are classically exemplified by

kwashiokor.

Kwashiokor is a nutritional syndrome primarily due to protein

deficiency. It develops after 6 months of age and connnonly between

1 and 4 years. It is prevalent in areas where starchy foods are the

staple diet. Tubers such as bananas, sago, and excessive sweetened

condensed milk with rice predispose children to the development of

kwashiorkor. The kwashiokor child is often irritable, lethargic and

anorexic. Tivial edema, easy pluckability of hair and depigmentation

at previous ulcer sites are pathognomonic signs.

Marasmus is the most common form of malnutrition in infancy.

It is primarily a caloric deficiency disorder due to insufficient and

over diluted milk formula as diet and symptomatized by recurrent

bouts of diarrhea and respiratory infections. The victim is emaciated,

active with voracious appetite and wizened old man facie.

Stevenson (1947) studied 263 infants from Boston, Massachusetts.

He observed that respiratory infection in the second half of the first

year of life was more prevalent among artificially fed infants. He

17

contends that the high vitamin A and ascorbic acid content of mother's

milk could have contributed to the stronger resistance of breastfed

subjects. The report by Norval and Kennedy (1949) on 417 cases from

Rochester, Minnesota indicated the opposite. In their series, the

breastfed children had a higher incidence of respiratory illness in the

same period of life. The discrepancies between the two studies have

been attributed to other variables influencing the result more than the

method of feeding.

Although not conclusive, findings by Bullen and Willis (1971) have

demonstrated that ~ coli is inhibited by the iron-binding protein

of milk. The study survey conducted by South-East England Faculty of

the Royal College of General Practitioners (1972) during the period

1968-1970 covered 334 children. Results showed that there was very

little difference in the incidence of infection between breastfed

and non-breastfed children.

Studies by Philips and Wharton (1968) confirmed the serious result

of bacterial infection in 75 malnourished children, composed of 63

kwashiorkors and 12 marasmic cases. The overall mortality was 13%

(9 cases) and management was particularly difficult due to the Salmonella

(garoli) strain which was highly resistant to chloramphenicol, tetra-

cycline and arnpicillin. It was emphasized that antibiotics be prescribed

only in the presence of particular infection such as skin, chest or

intestines and not to be given routinely.

In a post mortem study of 118 African children Schonland (1972)

showed bulk reduction of the thymus gland and peripheral lymphoid

tissue more marked in kwashiokors than in rnarasmus. It was proposed

18

that the stress situation in the infection caused the depression of

cell medicated immunity. The immunologic incompetence was a consequence

of nutritional deprivation (PCM).

In an effort to combat malnutrition, Cook (1971) was of the

opinion that hospital management of severe cases of malnutrition in

young children offered little advantage in cost and effectiveness of

service. Public health workers are convinced that detection and sur-

veillance of mild PCM cases would afford better means of prevention

and control if we are ever to solve the problem of malnutrition.

The preceding literature review has offered evidence to support

the contention that an ecological perspective on the study of malnutri-

tion is of considerable value. Not only diet of the child, but the

demographic and socio-cultural disposition of the mother is seen as an

important factor in determining the eventual nutritional.status of off-

spring.

METHODOLOGY

Sampling Procedure

Village Selection - The communities of St. Michael and I..alornas

were selected on the basis of the following criteria:

1. Study areas were adjacent to one another.

2. The two communities demonstrated differences in life styles.

3. A nutrition education program existed in one community

(St. Michael), while no such program was available in

the other connnunity (Lalomas).

4. In each connnunity there was a prevalence of cases of

protein-calorie malnutrition and other nutritional dis-

orders as documented by health records.

5. Respondents willingly participated in the survey.

Village Description - St. Michael and 1.alomas are two of the eight

districts that compose the community of St. Michael de L'Atalaye.

Both are located along the northwestern mountainous terrain of Haiti,

about 216 kilometers from the capital, Port-au-Prince. These north and

border sectors of the country are of low agricultural productivity as

compared to the more fruitful southern peninsula.

A majority of the Haitians are farmers by occupation, deriving

bare existence from the products of their small plots. Coffee is

the main cash crop of the more fortunate farmers. Connnon farm products

are beans, rice and plantain. Meat, poultry and fish serve as cash

crops and hence play a very limited part in the child's diet. Haitian

mothers are mostly housekeepers. Their important role in trade is as

19

20

market women. The market day system serves as a social outlet for the

women, who otherwise are always confined to the family and home chores.

Roads and transportation facilities are poor. Farm products are

carried to market by donkeys and on the head of the village women.

The size and site of the village varies depending upon the avail-

abilty of flat land and water supply. Cailles (village cottages) are

built of mud and sticks. They consist of one or two rooms with one

table and a couple of chairs. The hut usually includes a kitchen

located adjacent to or extending from the main house to prevent the

smoke from wood or charcoal from entering the cottage. Fruit trees

and vegetables abound. Domestic animals (chickens, pigs, goats and

dogs) are kept close to the cottage.

The social village structure is headed by the "Chef de Section."

Religion is closely associated with village life. Catholics are a

minority compared to the Baptists. Vodum and witch doctors still pre-

vail in isolated sections of the village.

St. Michael de Atalaye is the most progressive of the eight

districts. St. Michael serves as the focal point for the entire commun-

ity. It has an estimated population (1973) of 5,000 and one thousand

(1,000) houses. The HACHO (Haitian American Community Help Organization)

office supervises the activities of the medical clinic and Mothercraft

Center. Other coordinating agencies involved in community development

make St. Michael a very busy "bourge" (town). Two primary schools

(Baptist and Catholic) function under the guidance of Pastor Abraham

Lubin (Baptist Minister) and Fr. Peter (Catholic priest). The local

government offices (mayor's office, municipal jail, tax collector) for

21

for the eight districts are located in the community of St. Michael

de L' Alalaye •

Residential houses radiate from the plaza (town square) or are

crowded adjacent to the market place and public buildings. Houses are

constructed of the typical cailles material or concrete. Crowded houses,

improper toilet and sewage disposal, and muddy roads all add to the poor

sanitary conditions. The water supply comes from the river via an

electrically operated deep well. Children and adults tread long lines

to fetch water in their earthen jars or tin cans. Only the concrete

buildings are provided with faucets. Water from electrically operated

pumps is distributed at 6:00 a.rn. and 10:00 p.m. No telephone or mail

services are available. The nearest postal service was Gonaive which

is a one hour drive from St. Michael. Transportation facilities are

provided by private jeeps, HACHO vehicles, horseback or donkey.

The Mothercraft Center is an important feature of St. Michael. In

the concept of the Haitian Bureau of Nutrition, it is a practical

approach to the solution of the country's problem of malnutrition.

King (1967) indicated that a center's primary goal is nutrition education

of the peasant mothers in techniques compatible with their level of

understanding and limited financial resources. The typical connn.unity

Mothercraft Center operates 5 days a week, for a duration of 4 months.

Three to four mothers stay at the center daily and an average of 30

children are given two meals a day as prepared by the mothers under the

supervision of the "Responsible." Instruction in child care and sani-

tation are also included in the overall health education. The partici-

pating children are chosen from a village weight survey and are weighed

22

weekly while in the center. A child is admitted to the nutrition center

only if the mother agrees to actively participate in the program.

Criteria for the establishment of the Mothercraft Center include:

1. Established need as indicated by prevalence of cases of

malnutrition.

2. Geographically located to be easily accessible to the

targeted population and sector.

3. Active support of the community.

The commercial section of St. Michael consists of the market place,

local grocery stores, small retail stores, bakery and tailoring shops.

The market days are Tuesday and Friday. Food connnodities consist of

rice, corn, plantain (green bananas) and cassava. There are seasonal

fruits such as avocado, mango, melon, and citrus. Green leafy vegeta-

bles and eggplant, tomatoes and beans of all varieties are in abundance.

Meat is sold fresh or salted.

Lalomas is two kilometers north of St. Michael. It is largely

agricultural with rice, corn, coconut and beans as the main farm crops.

The population of the section surveyed is 800 with 150 houses. The

houses are constructed of connnon cailles material and dispersed further

apart atop a hill or along mountain slopes. Again, the kitchen is an

extension of the main house or separated from the hut. Kitchen utensils

include earthen pots or aluminum pans. Most of the homes raise domestic

animals such as dogs, goats and chickens. Without exception, a well-

kept garden plot adjacent to the house fenced by well-trinuned cactus is

typical.

Fourteen homes of the 108 interviewed had toilets (pit system or

23

or open hole). The water supply came mainly from two rivers and one

pump well located in the central section of the village with the

Baptist compound. Whereas, in St. Michael, administration comes from

the HACHO administrator, Dr. Mouliere Pamphile, in Lalomas the district

is headed by a very active president of the "Le Comite directeur ou

counceil communautaire de Lamine Lalomas."

Respondents.

The survey was undertaken during the month of July, 1973, spanned

three weeks (July 7-28), and covered 240 pre-school (0-4 years of age)

children each accompanied by an adult. Twelve individuals were excluded

from the sample because the interviewee was not the mother of the child.

A total of 228 subjects, 120 from St. Michael and 108 from Lalomas were

obtained. A purposive sampling method was used in the selection of the

participants. In line with the argument of Sanjor ~al. (1970):

The basic assumption behind purposive sampling was that with good judgment and appropriate strategy, one could develop a sample that was satisfactory in relation to one's need and relevancy on the dimension to be studied. If feeding practices and weaning habits were to be studied during the first months of life, if attitudes and beliefs of those women towards diet during pregnancy and lactation were to be explored, it follows that these features could only be studied by including in the sample women with children less than twelve months of age.

The Instrument.

The interview questionnaire was divided into three parts designed

to collect information on:

1. Section 1 - demographic data on family composition, maternal

characteristics (age, occupation and literacy level), child feeding

practices, types of infant feeding (mild), age at cessation of breast-

feeding and age of introduction of first semi-solids.

24

2. Section 2 - assessment of nutritional status by the use of

anthropometric measurements.

3. Section 3 - types of food given as transitional diet

(first semi-solids).

A copy of the instrument is presented in Appendix I.

Anthropometry.

Nutritional anthropometry is concerned with the measurements of

the variations of the physical dimensions and gross composition of the

human body at different age levels. The following paragraphs describe

the criteria employed in obtaining the various anthropometric measure-

ments used in this study.

Weight - Detecto Scales were used (calibrated in kilograms).

For children above three years old, the adult scale was used. For

children ages 0-36 months, the infant scale was preferred. Both scales

were placed on a firm surface and the lever accurately adjusted to zero

weight before measurements were taken. The subjects were weighed un-

dressed except for underwear. The young child (0-24 months) was placed

on the infant scale, whereas the older child stood at the center of the

platform of the adult scale. Weights were recorded in kilograms to the

nearest tenth. Gomez's classification of the degree of malnutrition

according to percent standard weight was used (Gomez et al., 1956).

Height - For height measurement, a steel rod attached to the

Detecto scale was adjusted to the desired level as the subject stood

at the center of the platform barefoot with feet firm, straight and

parallel to each other. For small children, crown of head to heel length

was measured with a measuring tape, fixed to a flat portable wooden

25

table (infantometer). All heights were recorded to the nearest 0.5 cm.

The Survey Team.

The survey team was composed of the student, a Haitian interpreter

and two volunteers (an American student nurse and a Haitian high school

student).

Site of Field Examination and Line of Flow - In St. Michael two

sites were selected and included the Medical Clinic building and a

vacant room of the Catholic school. The former station included sample

children from the mid-section to the southern end of the locality (dis-

trict), while the latter section included participants from the central

portion to the northern end of St. Michael. The presence and purpose of

the survey group was explained during the Sunday Services by both the

Baptist minister and the Catholic priest. The health personnel volun-

teered to inform mothers with 0-3 year old pre-schoolers to bring their

children for examination.

In Lalomas arrangements for the survey schedule were undertaken by

the minister, HACHO representative and a very active local council.

The Baptist compound, which was centrally located in the district, was

utilized as the third site for field examination. In all three stations

the standard procedure consisted of: (1) the receiving section where

the mothers were given numbers on their corresponding interview sheet;

(2) height and weight of sample children were taken and recorded by the

volunteer nurse; (3) clinical examination of children and measurement of

head, chest and mid-arm circumference and skinfold thickness by the

investigator; (4) interview of mothers by the Haitian interpreter.

26

Definition of Major Terms. The following definitions of terms are

employed throughout this study:

1. Nutrition the science of food and the nutrient as seen in

relation to health.

2. Public Health Nutrition - consists of the proper organization

of food supplies needed for the individuals and communities;

nutrition survey, nutrition education, supplementary feeding

and administration and planning are included in the area of

public health nutrition.

3. Undernutrition - the pathological state resulting from the

consumption of an inadequate quantity of food over an extended

period of time.

4. Malnutrition - the quality rather than the quantity of food

that is inadequate resulting in a relative or absolute de-

ficiency of certain essential nutrients.

5. Responsible - a young girl trained by the Haitian Bureau

of Nutrition and charged with the responsiblity of nutrition

instruction and supervision of participant mothers and children

in the Mothercraft Center.

6. Nutritional levels - refers to Stuart standard as given by

Jelliffe in the WHO monograph series no. 59. Assessment of

the nutritional status of the community.

7. Mothercraft Center - refers to a nutritional rehabilitation

center in Haiti in which the mother receives nutritional edu-

cation and the child serves as visual evidence of the ability

to rehabilitate malnourished children. (King, 1967).

27

Degrees of malnutrition or nutritional status were categorized

according to the Gomez classification and are as follows:

Third degree (severe) below 60% weight for age

Second degree '(moderate) 60-74.9% weight for age

First degree (mild) 75-90% weight for age

Normal over 90% weight for age

Nutritional and health status are terms used synonymously in this

study. Nutritionally vulnerable groups include pre-school children

(0-6 years of age) and lactating mothers.

Scope and Limitations of the Study.

The greatest hindrance to the in-depth investigation of the socio-

cultural variables employed in this investigation was the language

barrier. There was considerable difficulty in the translation of English

terms to local parlance (Creole). The inability of the Haitian inter-

preter to pursue answers that required elucidation, such as "certain

reasons for weaning", confounded the problem further. Mothers re-

sponded briefly and simply. An open-ended type of questionnaire would

be useful provided that sufficient time and greater inquiry were possi-

ble. However, detailed questioning further confuses the respondent,

increasing the risk of eliciting answers thought to please the inter-

viewer.

RESULTS AND DISCUSSION

As mentioned previously, the total sample was composed of 228

pre-school children and their mothers. For purposes here, the nutri-

tional status of the children has been dichotomized. Those moderately

or severely malnourished were grouped together, while normal children

or those displaying mild symptoms of malnutrition comprised the second

group. Of the 228 children, 78 or 34.2% of the sample were moderately

or severely malnourished and 150, or 65.8% normal to mildly malnourished.

Inlthis section we will endeavor to distinguish the two groups on the

basis of various characteristics such as age and literacy level of the

mother, age, sex and diet of the child and weaning practices.

Maternal and Family Characteristics

Table 1 presents the nutritional status of the child in relation

to mothers' age. A statistically significant difference between the

groups was not found; however, there appears to be a slight decrease

in the proportion of severely or moderately malnourished children of

women 36 years of age or older in comparison to children of younger

women. This pattern may be attributed to the possiblility that younger

women may have a greater number of children in nutritionally vulnerable

age group than women in the later stages of the child bearing years.

No data to support this contention was obtained from sample subjects,

however.

As demonstrated in Table 2, literacy level of the mother was not

a statistically significant factor in distinguishing the two groups of

28

29

TABLE 1. AGE OF MOTHER IN RELATION TO THE NUTRITIONAL STATUS OF THE CHIID

Nutrition Status of Child Mother's Age Moderate/Severe Normal/Mild Total

N % N % N %

15-25 15 31.3 33 68.7 48 100.0

26-35 33 37.5 55 62.5 88 100.0

36-45 12 29.3 29 70.7 41 100.0

46 + 2 25.0 6 75.0 8 100.0

Unknown 16 37.2 27 62.8 43 100.0

Total 78 34.2 150 65.8 228 100.0

x2 = 1.57 with 3 df (not significant)

30

TABLE 2. LITERACY LEVEL OF MOTHER IN RELATION TO NUTRITIONAL STATUS OF CHILD

Nutrition Status of Child

Moderate/Severe Normal/Mild Total Literacy Level of Mother N % N % N %

Literate 25 34.7 47 65.3 72 100.0

Illiterate 53 34.0 103 66.0 156 100.0

Total 78 34.2 150 65.8 228 100.0

x2 = 0.014 with 1 df (not significant)

31

women. For example, 34.7% of the children of literate mothers and 34.0%

of those of illiterate women were moderately or severely malnourished.

The six children of illiterate women aged 15 to 25 were generally under

two years of age, and with the exception of one child who was mixed fed,

all were completely breastfed. In contrast, nine of the children of

women of the same age who were literate ranged in age from 6 months to

3 years, and with the exception of one who was bottlefed, the remaining

eight were mixed fed. It appears, at least one the surface, that liter-

ate and illiterate mothers differ according to feeding practices, age

of children, and to a slight extent, the nutritional status of these

children. It may be that literacy and the greater child rearing exper-

ience (or fewer children in the nutritionally vulnerable age group) which

comes with age result in a slight decrease in the rate of malnutrition

of children. This trend is less evident for older illiterate mothers.

(See Appendix II for a breakdown of nutritional status of children

according to mother's age and literacy level.)

Table 3 presents the nutritional status of the sample children in

relation to family size, here interpreted as number of siblings. Be-

cause of the relatively small sample size, number of siblings has been

dichotomized into the groups one or two siblings and three or more.

This variable was not a significant factor in distinguishing between

moderately or severely malnourished children, and those who were normal

or mildly malnourished. While the age distribution of siblings was not

obtained, it may be a factor to be considered in the future. For ex-

ample, a high concentration of children in the nutritionally vulnerable

age group in one family should be expected to rapidly deplete the nutri-

32

TABLE 3. DISTRIBUTION OF CHILDREN ACCORDING TO NUMBER OF SIBLINGS AND NUTRITIONAL STATUS

Nutrition Status of Child

Moderate/Severe Normal/Mild Total Number of Siblings N % N % N %

1-2 32 33.7 63 66.3 95 100.0

3 or more 46 34.6 87 65.4 133 100.0

Total 78 34.2 150 65.8 228 100.0

x2 = .020 with 1 df (not significant)

33

tional value of an already insufficient diet.

Characteristics of the Chitd

The distribution of children severely or moderately malnourished

was not found to be random when age of the child was considered (see

Table 4). More specifically, children 0-12 months of age were signif-

icantly different from the older children in the sample (x2 = 23.2 with

3 df, a= .05), in that they tended to have fewer numbers in the severe-

ly or moderately malnourished category. This finding may, in part, be

attributed to the likelihood that younger children have only recently

been weaned, if at all, and are therefore less vulnerable to nutritional

deficiencies.

While age was a significant factor in discriminating between the

two groups of children, sex was not found to be important (Table 5).

The sa~ple was approximately equally composed of males and females (111

males, or 48.7% vs. 117 females, or 51.3%). Only a slightly smaller

proportion of males than females (33.5% males vs. 35.0% females) was

classified as moderately or severely malnourished.

Table 6 presents the nutritional status of children in relation to

the type of milk feeding received. A Chi-square analysis revealed no

significant differences among the groups. While bottlefed children

appear to be less severely malnourished, the number in this category

is so small (N=7) that further interpretation would be superficial at

best.

Age at the first introduction of semi-solid foods was not found to

appreciably distinguish between the groups (see Table 7). Those children

not yet receiving semi-solid foods, however, displayed a slighter inci-

34

TABLE 4. DISTRIBUTION OF CHILDREN ACCORDING TO AGE IN MONTHS AND NUTRITIONAL STATUS

Nutrition Status of Child

Moderate/Severe Normal/Mild Total Age of Child N % N % N %

0-12 15 16.3 77 83.7 92 100.0

13-24 27 42.2 37 57.8 64 100.0

25-36 26 52.0 24 48.0 50 100.0

37 + 10 45.4 12 54.6 22 100.0

Total 78 34.2 150 65.8 228 100.0

x2 = 23.2 with 3 df significant a = .05

35

TABLE 5. DISTRIBUTION OF CHILDREN ACCORDING TO SEX AND NUTRITIONAL STATUS

Nutrition Status of Child

Moderate/Severe Normal/Mild Total

Sex N % N % N %

Male 37 33.3 74 66.7 111 100.0

Female 41 35.0 76 65.0 117 100.0

Total 78 34.2 150 65.8 228 100.0

x2 = 0.06 with 1 df (not significant)

36

TABLE 6. DISTRIBUTION OF CHILDREN ACCORDING TO TYPE OF INFANT FEEDING (MILK)

AND NUTRITIONAL STATUS

Nutrition Status of Child

Moderate/Severe Normal/Mild Total Type of Feeding N % N % N %

Breastfed 46 34.1 87 65.9 133 100.0

Mixed Fed 31 36.0 57 64.0 88 100.0

Bottlefed 1 14.3 6 85.7 7 100.0

Total 78 34.2 150 65.8 228 100.0

x2 = 1.36 with 2 df (not significant)

37

TABLE 7. DISTRIBUTION.OF CHILDREN ACCORDING TO AGE AT FIRST INTRODUCTION OF SEMI-SOLID FOOD

AND NUTRITIONAL STATUS

Nutritional Status of Child

Age at intro- Moderate/Severe Normal/Mild duction of first semi-solid (months) N % N % N

0-6 66 34.6 125 65.4 191

7 + 9 36.0 16 64.0 25

No semi-solids 3 25.0 9 75.0 12

Total 78 34.2 150 65.8 228

x2 = 0.49 with 2 df (not significant)

Total

%

100.0

100.0

100.0

100.0

38

dence of severe or moderate malnutrition. Again, as was the case with

bottlefed children, the number in this category is too small to allow

further speculation.

Whether or not a child had been weaned was a statistically sig-

nificant factor in assessing nutritional status (see Table 8). Children

not yet weaned were predominantly classified as normal or mildly mal-

nourished (75.4%) while those who had been weaned were more likely to

be moderately or severely malnourished (46.0%). A Chi-square value of

11.4 (df=l) was significant at the a=.05 level. This factor lends

credence to the previous finding that younger children were more ade-

quately nourished than older children.

The distribution of the samples according to community of residence

is presented in Appendix III. As displayed in Appendix IV, the mean

duration of milk feeding ranged from 15.9 to 21.6 months. The mean age

for the introduction of semi-solids ranged from 17.3 to 18.8 months.

Some children received semi-solids as early as two months of age.

Additional Observations

A comparative assessment of the infant feeding practice in the two

communities, St. Michael (urban) and Lalomas (rural) clearly illustrates

the influence of life style or social mobility on the child's dietary

pattern. Whereas, in St. Michael 27 sample children were breastfed, the

number in Lalomas was 106. On the other hand, 86 participant children were

mixed fed in St. Michael and only 2 in Lalomas. As a whole, 221 (97%) of

the children received mother's milk.

As indicated in table 2, there was no significant difference in the

Weaning Practice

Not Weaned

Weaned

Total

39

TABLE 8. DISTRIBUTION OF CHILDREN ACCORDING TO WEANING PRACTICE AND

NUTRITIONAL STATUS

Nutritional Status of Child

Moderate/Severe Normal/Mild Total

N % N % N %

31 24.6 95 75.4 126 100.0

47 46.0 55 54.0 102 100.0

78 34.2 150 65.8 228 100.0

x2 = 11.4 with 1 df (not significant a = .05)

40

nutritional status of children, of literate or illiterate mothers. In

this study the index for literacy was the indicated ability to read and

write.

Of 228 respondent mothers, 189 (83%) were housekeepers and 39 (17%)

were shop keepers. Of the housekeepers, 68.3% solely breastfed and 31.7%

mixed fed, while among mothers with other occupations, 74.4% mixed fed and

·only 12.8% breastfed. Thus, the greater the demands on the mother, the

greater her tendency to supplement her milk.

It was reported by 48% of the respondent mothers that children were

often ill between birth and weaning time.

The detrimental effects of poor quality contaminated transitional

diet is strongly suggested. In order of frequency, the food items intro-

duced as transitional diet were boiled cassava, plantain, vegetable soup

(legume), egg and rice or corn gruel. Sources of advice on child feeding

included the mother herself, Mothercraft responsible, health personnel,

and peers.

There was no change in the diet for women during pregnancy and

lactation; seventy-one percent of the mothers reported that they did

not modify their dietary patterns during these periods.

In this study, weaning has the actual cessation of mother's milk.

The two most connnon reasons for weaning given were as follows: (1) it

was time to wean; (2) the onset of another pregnancy. The former referred

to the ability of the child to walk and to chew solid foods. The weaning

process was gradual and generally consisted of painting the breast with a

bitter substance called Lalua. The reasons and methods point to a tradi-

tionally inclined practice.

41

As indicated in table 8, sample children who were not weaned were

nutritionally better than those already weaned. Of the unweaned child

participants eighty-one were infants, thirty were two years old, and

twelve over two years. Age still counts as an important variable.

The prevailing infections were colds, diarrhea, and dermatitis

(scabies). Bilateral neck adenj_tis was observed in 70 cases; parasitism,

conjunctiva! pallor and enlarged abdomen were frequently observed. Eight

cases of PCM 94 kwashiorkor and 4 marasmus) and evidence of iron and

vitamin A deficiency are documented in Appendix V.

SUMMARY AND CONCLUSIONS

A cross-sectional survey was undertaken in the conununities of

San Michael and 1.alomas, Haiti in July 1973. The sample included 228

pre-school children and their mothers. Assessment of the nutritional

status of the participant children in relation to the feeding practices

and weaning habits of their mothers was conducted.

Among the demographic variables considered, only the age of the

child was a relevant determinant of the health status of the children.

This was recognized by the Haitian Bureau of Nutrition and motivated

the establishment of a nutrition center (Mothercraft) in St. Michael.

Reports of a high incidence of protein-calorie malnutrition in the

community was not practical at the time of the survey.

Of the total sample, 78 children (34.2%) were found to be moderate-

ly or severely malnourished. There was a significant relationship be-

tween the age of the children and their nutritional status. Children

0-12 months of age evidenced consistently fewer cases of moderate or

severe malnutrition than those over 13 months of age. The pattern

appeared to be consistent in both couununities. There was no apparent

association between the type of inf ant (milk) feeding and the level of

nutritional status. However, children who had been weaned displayed

a greater incidence of moderate or severe malnutrition, and this finding

was statistically significant. The early introduction of poor quality,

contaminated transitional foods seems to contribute to frequent illness

before weaning time and therefore, appears to be nutritionally detriment-

al. Poor sanitary conditions - primarily the lack of toilet facilities -

42

43

foster a high prevalence of parasitism, anemia and vitamin A deficiency.

In the presence of general good dental condition, the frequent bouts of

cold and bilateral neck adenitis are highly suggestive of a tuberculous

infection prevalent in tropical and subtropical regions.

Little variation in diet for pregnant and lactating women was

reported. The transitional diet for children in the weaning process

consisted primarily of foods available in the community, such as cassava,

plantain and legumes.

The importance attributed here to the age of the child and the stage

at which he is weaned seems to suggest the propitious nature of adopting

an ecological perspective for the study of malnutrition. Future research

in this area should concentrate more closely on family composition; more

specifically, what is the influence of the presence of two or three

children in the nutritionally vulnerable age group on the nutritional

status of a target child. While younger women in this sample had a

larger proportion of children in the moderately or severely malnourished

category, it was not determined specifically whether or not this phenom-

enon was due to mother's age or the prevalence of more children in the

nutritionally demanding age category. The malnourished child must not be

examined in isolation - to the extent that he is a member of an ecological

system such as the family, the cause and incidence of malnutrition must

be examined from the standpoint of the family as a unit.

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Appendix I

48

49

An Investigation on

Infant and Child Feeding and Weaning Practices and Health Attitudes in Rural Haiti

HNF - VPI & Su

Ma. Stella V. Gonzales, M. D.

50

Part I. Interview Sheet

Interview No. ------Identification of Family

1. Date (day/month/year)

2. Locality

3. Name of target child

4. Sex of target child male female ------5. Date of birth (day/month/year)

Sa. Date of birth of next older sibling '---------------------~

6. Source of information of child's birthdate

a) birth certificate ------b) Mother's memory -------c) Other ------ Specify: ---------------------~

7. Name of parents or guardian

a) father

b) mother

c) guardian

8. Is the target child living with

arents: father yes ______ no _____ _

mother yes ______ no _____ _

or guardian ------· grandmother _____ _

aunt ------sister ------neighbor _____ _

other ------9. How many children were born alive? _____ _

How many children have died? ________ ~ So you have had total children.

51

10. Have you and any of your children participated in a nutrition center

yes _____ _ no ------11. In feeding your child do/did you

a) breast feed yes __ no b) bottlefeed yes no

if yes, skip to question 15 c) both breast feed and bottlefeed yes __ no d) used a wet nurse yes __ no

12. How soon after birth was the child breast fed?

a) within 5 hours b) 6-12 hours c) 13-24 hours

13. How often is the child breast fed?

a) when the child cries b) nights only c) other, specify

14. Are you still breast feeding your child yes ___ no __ _

If yes, when do you plan to stop breast feeding?

0-3 months 19-24 months -------- ---------4 - 6 months 25 - 36 months -------- ---------7 - l 2 months -------- When pregnant again -----13-18 months -------- Other ___________ ~

If no, how old was your child when you stopped breast feeding?

0-3 months 19-24 months -------- ---------4 - 6 months 25 - 36 months -------- ---------7 - l 2 months -------- When pregnant again _____ _ 13-18 months -------- Other ___________ ~

Why did you stop?

a) no more milk b) another pregnancy c) illness d) Other Specify: ____________ _

(For Mothers who bottle feed)

15. Why did you choose to bottle feed your child?

52

a) convenient b) is modern c) mother has to go to work d) mother's milk insufficient e) advised by relative and peers f) other

16. When did you first start bottle feeding?

a) from birth d) 13-24 months b) 3-6 months e) 25-36 months c) 7-12 months

17. How often do you bottle feed the child?

a) when the child cries b) alternating with breast feeding c) other

18. What do you bottle feed your child?

a) milk ------whole milk condensed milk evaporated milk powdered milk other

b) fresh fruit juice ------specify kind of juice:

~------------------------

c) Other -------19. How do you clean the bottle?

a) with boiling water ------b) with cold water -------c) with water and soap -----d) other Specify: ---------------------~

20. Why did you choose not to breast feed your child

a) didn't want to start b) couldn't (but wanted to) c) baby would not suck d) advised against it e) mother has to go to work

Who, if anyone, advised the mother not to breast feed?

53

a) relative -:---------b) neighbor/friend -----c) other ~--------~

21. At what age do you wean the child?

a) 3-6 months d) 17-24 months b) 7-12 months e) 25-36 months c) 13-18 months

22. Reasons for weaning

a) mother is ill b) mother needs to work c) child refuses to suck d) child is ill e) another pregnancy f) social reasons g) other_~ Specify __________________________ _

23. What special practice do you use to wean the child?

a) none b) bush tea c) bush tea and purgative d) lemon and linseed e) sleep away from mother f) geographical separation ------g) other_~ Specify=-------------------------~

24. If she were to have another baby, would she breast feed again?

yes ------ it depends ------no don't know ------If no, why not?

a) baby's health b) need to go to work c) inconvenient for mother d) mother's figure e) husband's preference f) relatives preference g) other _________________ Specify ___________ ~

25. When were/will liquids or semi-solid foods first introduced?

a) less than 3 months b) 3-6 months c) 7-12 months

54

d) 13-18 months e) when child had its first tooth f) when child started to refuse the bottle or breast milk

~~~~~~~~-

26. What are these foods?

a) gruel Specify b) vegetable soup c) mashed yam d) boiled potato e) boiled cassava f) egg g) special connnercial food Specify h) soft portion of family meal

27. Who suggested that you use these foods?

28. Do you prepare a special weaning food for the child? yes __ no

If yes, name the food

29. At what age does the child eat entirely from the family pot?

a) 6-12 months c) 19-24 months b) 13-18 months d) other reasons

30. Who cooks the family food?

a) mother b) grandmother c) older daughter d) bought from the store already cooked

31. How do you feed the child?

a) feed it with your hand b) feed it with a spoon c) teach it how to eat by itself

32. Where do you get your water?

a) faucet c) spring b) deep well d) river

(Mother's attitudes and practices during pregnancy and lactation)

55

33. Do you need special care during pregnancy? yes no ~~~

If yes, specify what kinds of special care needed.

34. Why do you feel you need this special care

a) they were given by the health personnel (Dr., Nurse) b) it was advised by a friend or relative c) I heard on the radio that it was good

35. Do you eat any special food during pregnancy and while breast feeding?

yes ~~ no ~~

If yes, ask the mother to name the food ~~~~~~~~~~~~~~~~~~

36. Why do you eat these special foods?

37. Do you avoid certain foods during pregnancy and lactation? yes~~ no~~

If yes, what foods do you avoid during these periods?

38. Why do you avoid these foods?

(Mother's attitudes toward health practices)

39. Has your child ever had trouble with these conditions?

a) frequent colds b) soft stool (not watery) c) abdominal pains d) lack of appetite e) excessive appetite f) night blindness g) other

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

56

40. When your child is sick, do you seek treatment for the child? yes no ~---

If yes, where do you get treatment for the child?

a) health clinic b) self-medication c) advise of relatives d) quack doctor

41. When did you first notice your child was not well?

a) since birth b) between birth and weaning c) during the period of weaning d) after the child was weaned

42. What do you think causes sickness in children?

a) disease b) evil spirit c) normal process of child growth __ _ d) other Specify

~----------------------~

43. Do your children use a toilet?

a) don't have a toilet b) they are afraid to use the toilet c) we share the neighbor's toilet

(Information on Mother)

44. Age of mother

a) 15-25 years b) 26-35 years c) 36-45 years d) 46 and over

45. What is her principal work?

a) housework alone b) housework and farming ---c) factory worker d) shop keeper e) domestic (cook, maid) f) market woman g) government employee

51

46. What level of schooling has she completed

a) none b) little, can read and write c) primary schooling completed d) secondary schooling completed e) part secondary schooling completed ~~~

47. How old was she when she had her first baby?

a) 15-20 years old b) 21-30 years old c) 31-40 years old

58

Part II

Anthropometry and Clinical Examinations

1 • Child's name

2. Examination number

Anthropometry

3. Weight lbs. oz. or

kg.

4. Height/Length (delete one) inches

or cm

5. Head circumference cm

6. Chest circumference cm

7. Mid-arm circumference cm

8. Triceps Skinfold nnn

9. Teeth (number erupted upper lower

Remarks:

Do the remarks directly affect anthropometry (e.g., hydrocephalus, missing limb)? yes no -----

Clinical Examination

(Check unequivocal signs only)

10. Hair: Thin and sparse Proximal dyspigmentation

11. Eyes: Xerosis Keratomalacia Conjunctival pallor

12. Lips: Angular stomatitic Cheilosis

APPENDIX II. SPJ!PLE DISTRIBUTION OF MOTHERS ACCORDING TO AGE GROUPS AND LITERACY LEVELS IN RELATION TO THE NUTRITIONAL STATUS OF CHILDREN

N = 228

AGE LITERATE ILLITERATE ALL CHILDREN GROUPS Nutritional level of Nutritional level of Nutritional level

Children Children of Children (Years) Mod/Severe Normal/Hild Mod/Severe Normal/Mild Mod/Severe Normal/Mild

N % N % N % N % N % N %

15-25 9 45.0 11 55.0 6 21.4 22 78.6 15 31.3 33 68.7

26-35 10 30.3 23 69.7 23 41.9 32 58.1 33 37.5 55 62.5

36-45 6 31.6 13 68.4 6 27.3 16 72. 7 12 29.3 29 70.7 \JI \C

46 + 0 0 0 0 2 25.0 6 75.0 2 25.0 6 75.0

Age unknown 0 0 0 0 16 37.2 27 62.8 16 37.2 27 62.8

TOTAL 25 34.7 47 65.3 53 34.0 103 66.0 78 34.2 150 65.8

St. Michael and Lalomas, Haiti West Indies July 1973

60

APPENDIX III. DISTRIBUTION OF SAMPLE CHILDREN IN RELATION TO DEGREES OF MALNUTRITION IN BOTH COMMUNITIES

N = 228

COMMUNITIES Degrees of Malnutrition TOTAL Moderate/Severe Normal/Mild

N % N % N %

St. Michael 45 37.5 75 62.5 120 100

Lalomas 33 30.6 75 69.4 108 100

TOTAL 78 34.2 150 65.8 228 100

St. Michael and Lalomas, Haiti West Indies July 1973

x2 = 1.22 df = 1 (not significant)

COMMUNITIES

ST. MICHAEL

LALO MAS

APPENDIX IV. MEAN DURATION OF MILK FEEDING AND MEAN AGE FOR INTRODUCTION OF SEMI-SOLID FOODS IN BOTH COMMUNITIES

MEAN DURATION OF MILK FEEDING

BREASTFEEDING BOTTLEFEEDING

18.20 mos. 21.60 mos.

15.90 mos. none

MIXEDFEEDING

19.6 mos.

19.0 mos.

SEMI-SOLID FEEDING STARTED MEAN

AGE AS IN MONTHS

18.8

17 .3

Q\ ....

62

APPENDIX V. NUMBER OF CASES WITH CLINICAL SIGNS IN RELATION TO NUTRIENT DEFICIENCIES IN THE TWO COMMUNITIES AT THE

TIME OF SURVEY

Clinical Signs

1. Vitamin A deficiency

2.

xersis keratomalacia follicular hyperkeratosis nyctalopia (night blindness)

Protein deficiency thin sparse hair proximal dysprigmentation bilateral edema kwashiorkor

3. Calories deficiency marasmus

4.

5.

6.

7.

Anemia conjuctival pallor

Parasitism

Jaundice (yellowish discoloration of the conjuctiva)

Infections bilateral adenitis scabies seborrheic dermatitis

8. Dentition whitish, clean with carious teeth

Connnunities

St. Michael

3 1 4

11

38 53

8 4

4

97

55

11

59 43

3

82 11

Lalomas

0 0

11 7

12 29

0 0

0

64

39

8

11 25

5

74 12

The vita has been removed from the scanned document

COMPARATIVE ASSESSMENT OF THE NUTRITIONAL STATUS OF HAITIAN CHILDREN DURING THE TRANSITIONAL PERIOD

IN TWO HAITIAN COMMUNITIES

by

Ma. Stella Gonzales

(ABSTRACT)

The research reported in this study focused on the Ecosystem

Approach as the ecological model most appropriate for the study of the

nutritional status of pre-school children and the key roles played by

the home and family environment. Sample subjects included children in

the nutritionally vulnerable years (0-4 years) and their mothers.

The sample consisted of 228 Haitian children, 108 from the community

of Lalomas, and 120 from St. Michael. The latter of the two sample areas

is considered to be the more progressive of the two. While a Mothercraft

Center had been in operation for 8 months in St. Michael, no nutrition

education program was available in Lalomas. The short duration in which

the Nutrition Center had been in operation prevented measurement of its

impact on the community.

Feeding habits, weaning practices, transitional diet, nmnber of

siblings in the family, and age and literacy level of the mother were

areas investigated in the study. The nutritional status of children

was determined via height and weight measurements and comparison to the

Stuart's standard.

Over one-third of the children (34.2 percent) were classified as

moderately or severely malnourished. Younger children (0-12 months),

and those not yet weaned, evidenced consistently fewer cases of moderate

or severe malnutrition. This pattern was apparent in both connnunities.

The transitional diet was found to be characterized by foods readily

available in the community, e.g., cassava, plantain and legumes.

It is suggested that future research concentrate on the age

composition of the family; specifically, are families composed of

several children in the nutritionally vulnerable age category more prone

to lower nutritional status than families with only one vulnerable child.